Application for Victor J. Teichner Award

Application available online at www.AAPDP.org

Instructions: There is no limit on the length of the information supplied below. Download and save this form. Rename it as “Name of Program – Teichner Application” and, when completed, email it as a WORD document to . Submissions will be acknowledged.

Name of Program:

Name of Director:

Mailing address:

Street address:

Phone: Fax:

Email address:

Contact person and contact information if different from above:

(Note: Contact person may be other than the Program Director)

Part 1: Tell us about your training program.

1) Please describe your program, your residents, the population you serve, and the clinical settings in which the residents are trained.

2) Please give us an overview of the curriculum you have developed for educating your residents in psychodynamic principles.

3) Please comment on the didactic areas that might be added or improved as well as the presence and adequacy of clinical supervision. What do you need?

4) Is there a psychoanalytic institute or specific training programs in psychodynamics easily accessible in your area? If so, please describe the relationships you have developed with this program, or the barriers to such a collaboration.

Part 2: How can we help you?

1) How would you use a 2-3 day visit to enrich your program? Please articulate as best you can what would be of particular use and interest to your trainees and your faculty.

2) a. Describe in as much detail as possible how you would envision the structure of the Scholar's visit and the various settings you would arrange for teaching and supervision

b. We have learned that one of the elements that help residents get the most out of the experience is to have ‘release time’ from their scheduled clinical and service commitments. We therefore suggest a mixture of activities for the residents. Some that involve all, some that involve individual years of the residency, to facilitate full participation of all residents. Do you think you will be able to arrange release time for the residents?

Signature (required, may be electronic)______

Program Director

This completed form must be emailed to:

Last date for receipt of application for the 2011 Academic Year is: November 1, 2011